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'+b•i <br /> t I APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f I 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) Y10 -0,2— <br /> Application <br /> 1O -0,2Application is hereby made to theSanJoaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaq in Coulty Ordinance No. 9 for sewage oTa. 1862n elllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. /w '1'r�Rt�jf � o.° -td .Y 14 y„x �z <br /> S /� I L City 4 - Lot Size PM <br /> Job Address <br /> ! I <br /> Owner's Name �� �� � ddress l'�C�a _ Phone <br /> Contractor <br /> �� � 'Addressf ense No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONS <br /> PUMP INSTALUTION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> III <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F-1Industrial L1 Open BottA L1 Manteca Dia. of Well Excavation Dia. f Well Casing <br /> k ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public F1 Other !I� ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pumpi H.P. State Work Done_ <br /> { l� e0 G Gd <br /> Well destruction Well Diameters Sealing Material Ito <br /> Depth a 50 Filler Material {Belo I 3/ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [ I REPAIR/ADDITION 1 I DESTRUCTION l I (No seavailabpti cystithin m permitted if public sewer is <br /> Installation will serve: Residence_' Commercial__ Other <br /> Number of living units: Numb r of bedrooms GQY <br /> Character of soil to a depth of 3 feet:q Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> I <br /> k PKG. TREATMENT PLT. ❑ Method of Disposal <br /> P <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance A nearest: Well Foundation Property Line <br />!k SEEPAGE PITS t I DepthF Size Number <br /> t SUMPS CI Distance It-11 nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ .�I ` <br /> a <br /> I hereby certify that I have prepared this'application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and s <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signatu�'e certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> k employ any person in such manner as tol�become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in ilia performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." II� <br /> k The applicant M-PS41c t or requi s ctions. Complete drawing on reverspjside. <br /> Signed X <br /> u Title: <br /> li <br /> RDE PARTMENT USE ONLY <br /> Application Accepted by � � I° r`^ 5 Jua-­­, Date ate' v Area ���/(/ <br /> Pit or Grout Inspection by IIII Date Final inspection by Date lhy�— <br /> Additional Comments: - <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant Return all copies to: Enviromental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> II <br /> FEEAMOUNT DUE . AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> ♦.EH13-244REv.i/H5f '. � <br /> EH 14-2a 444 <br /> ill <br />